Turbulence, Fluid Waves, and the Black Hole

A 61-year old male developed an acute exacerbation superimposed on a 3-month relapsing and remitting course of painless eyelid swelling beginning in the right upper lid progressing to involve both upper and lower eyelids, malar area, and temporalis. He provided photographic documentation of dramatic waxing and waning course, sometimes preventing him from opening his eyelids (Figure 1). His condition was poorly responsive to repetitive courses of antibiotics and corticosteroids, but showed mild improvement with compressive dressing. The patient denied a pulse synchronous bruit. However, when questioned about auditory symptoms, he described a "rushing fluid" sound when he digitally compressed the eyelid tissues. He denied previous trauma or surgery. He worked as a truck driver and had strong inclination to "selfies", providing ample documentation of his waxing and waning course of eyelid edema. Examination showed severe right upper and lower eyelid demarcation extending to the malar and temporalis areas, without tenderness, erythema, or proptosis. The remainder of the slit lamp and funduscopic examinations were normal. CT orbit obtained prior to presentation reported "significant right periorbital swelling without other abnormalities" but images were unavailable. T1 orbital fat suppressed contrast enhanced axial and coronal imaging and T2 axial and FLAIR images demonstrated diffuse enhancement and enhancing collection of the fluid in the right upper eyelid, malar, and temporalis regions on T1 sequences (Figure 2A and 2B) that were bright on T2 (Figure 2C) and demonstrated signal suppression on FLAIR (Figure 2D). Radiology report summarized the findings as "large phlegmon or abscess overlying the orbit without post-septal involvement." CBC with differential, urinalysis, HIV, and blood culture were normal. A biopsy was performed for intra-operative study to confirm the diagnosis.